Case 1
An 86-year-old woman was diagnosed with RA at the age of 83 years. Due
to the high disease activity of RA, she received tofacitinib (5 mg/day).
This treatment did not significantly improve her disease activity score
28 (DAS28) score, which was initially 3.07 and improved to 2.93 after 3
months of drug therapy. The bone mineral density T-score of the left hip
was -2.8, and she was subsequently diagnosed with osteoporosis. However,
she received no treatment because she had not been prescribed a
glucocorticoid. She complained of both gait and weight-bearing pain with
varus deviation in the left ankle joint (Figure 1 A–C). At her initial
visit, the radiographic findings in her left ankle joint were Larsen
Grade IV in the talocrural joint and Larsen Grade III in the subtalar
joint (Figure 2 A, B). Triamcinolone acetonide (15 mg) was injected into
the left talocrural joint 5 months before surgery, but pain and swelling
persisted. We decided to perform ankle arthrodesis to improve the
patient’s functional outcome.
We used a transfibular approach during surgery. Both the talocrural and
subtalar joints were exposed, and each joint surface was curetted. The
finned intramedullary retrograde ankle nail (Intramedullary nail with
fin, Teijin Nakashima Medical, Co. Ltd., Okayama, Japan) was inserted
from the plantar side. Cancellous bone grafts were performed using bone
harvested from the distal fibula (Figure 3 A, B).
After surgery, non-weight-bearing was maintained for 3 weeks. A patellar
tendon-bearing orthosis was applied, and walking exercises were started
3 weeks after surgery. The orthosis was released, and free gait with
full weight-bearing was started 3 months after the surgery.